OPINION
DOCTORS' Lounge
take money on many occasions, but said,
“Save the money to buy food. You can pay
me later.”
During and after my 1967 internship
year here at St. Joseph’s Infirmary, I was
mentored by such men as Drs. John Hem-
mer, Bernie Popham, Richard Roth, Frank
Jelsma and Henry Asman. All of them were
different in their own way, but they knew
the importance of being a model for the
younger generation. They spoke in a gentle
manner (on most occasions), and they were
respectable and respectful. They inspired
respect by their speech and gesture. I always
wanted to emulate them. The great concept
that Drs. Hemmer and Jelsma taught me
was, “You don’t have to agree with everyone
but always be respectful. Others may not
like that you disagree but, as long as your
conscience is clear, you will have peace in
your heart.”
We must mentor the next generation.
There were times during my private prac-
tice when students from business school or
medical students in community rotations
came to learn the ways of the older gener-
ation. The present focus on the business of
medicine has changed the way we deliver
care. There is less caring and more delivery.
Now many, many doctors work for cor-
porations, and have very little to say about
the practice of medicine. We are told to
code correctly and “higher” to generate
more revenue. If the coding is lower and
not enough money is brought in, we are told
to have more education. The more money
we generate, the more bureaucracy is built
into the system, and we are provided with
more managers to manage the doctors.
I was surprised when microscopes were
removed from certain facilities because it
was determined by the “leadership” that
“maybe the lab assistants were not properly
trained to read the clue cells or white cells.”
Therefore, we were told to run the urine
dip as a print out and then send all urine
for culture, “because there is a lot of anti-
biotic resistance.” Most of the people who
make such decisions usually do not work as
doctors and cannot possibly fathom the im-
portance of Leuwenhoek’s discovery. I was
told that RVUs are important and coding is
not really based on medical necessity, but
medical decision making. There was a time
when we, doctors, looked at the slides for
malaria and white cells and giant cells and so
on. It has become a lost art. In the mid-six-
ties, we did our own microscopic readings.
It is not for everyone to recognize Puffer
cells of synovial sarcoma or poached egg
cells of Oligodendroglioma, but that is not
really what we are battling with these days.
One of the most common causes of frus-
tration is the practice of giving a bonus to
the providers. Some criteria are prepared
to make the system look equitable. But in
reality, the providers (as insurers are called
these days) are told in a very subtle manner
to generate more revenue. One of my man-
agers once told me that “Look if you don’t
code higher, you are just giving benefit to
the insurance company, not to the patient.”
I swallowed my pride and listened. I was
told that RVUs are important in deciding
bonus and medical necessity is only one of
the elements in deciding about coding for
services. I remembered that I had gone to a
local hospital for aspiration of some blood
from my elbow, and after the procedure was
finished I asked for a Tylenol pill. When
I received the bill, I noticed there was an
additional charge for ten dollars, and so I
called the administrator of the hospital com-
plaining about the charge. He reminded me
that, when we check into a hotel, the actual
payment is not what is written on the back
of the door in the room.
There are times when a company moni-
tor is assigned to check on a doctor’s coding
practices; to me that felt like intimidation.
I feel that as doctors we must resist such
controlling behavior and do only what we
believe is right.
The New England Journal of Medicine
(NEJM) published an article about the bo-
nus system and how it corrupts doctors.
Aristotle had said (I am paraphrasing) that
we are humans first, and next we are our oc-
cupation. I do not wish to pillory the system
without an answer or solution. I believe we
should be judged by our patients and our
subordinates, and not by our colleagues
whom we play golf with, and not by how
we consider coding and charges.
Dr. D. Khullar et al. in the NEJM of June
11, 2015, addressed the issue of “Behavioral
economics and physician compensation—
promise and challenges.” It took us many
years to recognize that we need second
opinions before removing the uterus from
someone and slowly we are moving towards
a similar phenomenon before performing
lumbar fusions for disc degeneration. Nu-
merous series (three in sequence) of epi-
dural injections are given to patients with
back pain, despite studies that have shown
that there are no long-term benefits and the
effects are equal to placebo at best.
I think we have to be mentors for the
next generation and teach evidence-based
medicine. Dr. William E. Hunt, in his 1971
presidential address to the Neurosurgical
Society of America, said that if we act as
business entrepreneurs, we will be treated
as such by society. We will lose the privilege
we enjoy from being doctors and profession-
als. 1 Timothy 6:10 said it best: “The love
of money is the root of all evil.” We often
forget that as we continue our journey of
medicine. We are obviously bright in high
school; we excelled as undergrads to get
into medical school, and most of us grew up
with a sense of morality. The enticement of
the dollar is genuine and I feel it has to be
quelled in our heart in a deliberate manner.
Otherwise we might end up justifying our
actions to seek advantage.
The NEJM article stated, “Behavioral
economics views incentives as fundamental
determinants of behavior, and it can help
elucidate how the timing, frequency and
amount of payment influence behavior.” I
never forget the fact that I try to see myself
in the best image possible and there are
times when my sense of entitlement might
interfere with listening to advice contrary
to that self-perception. Physicians, be self-
aware.
Dr. Banerjee is the Clinical Professor of Neuro-
surgery at the University of Louisville.
APRIL 2019
29